Sec. 8. Prohibiting balance billing practices by providers for emergency services, for services furnished by nonparticipating provider at participating facility, and in certain cases of misinformation
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Part A of title XI of the Social Security Act ( 42 U.S.C. 1301 et seq.) is amended by adding at the end the following new section: In the case of an individual with benefits under a group health plan or health insurance coverage offered in the group or individual market who is furnished in a plan year that begins on or after January 1, 2022, emergency services with respect to an emergency medical condition during a visit at an emergency department of a hospital or an independent freestanding emergency department— if the hospital or independent freestanding emergency department does not have a contractual relationship with such plan or coverage for furnishing such services, the hospital or independent freestanding emergency department shall not bill, and shall not hold liable, the individual for a payment amount for such emergency services so furnished that is more than the cost-sharing amount for such services (as determined in accordance with section 2719A(b) of the Public Health Service Act, section 716(b) of the Employee Retirement Income Security Act of 1974, or section 9816(b) of the Internal Revenue Code of 1986, as applicable); and a health care provider without a contractual relationship with such plan or coverage for furnishing such services shall not bill, and shall not hold liable, such individual for a payment amount for such services furnished to such individual by such provider with respect to such emergency medical condition and visit for which the individual receives emergency services at the emergency department of the hospital or independent freestanding emergency department that is more than the cost-sharing amount for such services furnished by the provider (as determined in accordance with section 2719A(b) of the Public Health Service Act, section 716(b) of the Employee Retirement Income Security Act of 1974, or section 9816(b) of the Internal Revenue Code of 1986, as applicable).
Subject to paragraph (2), in the case of an individual with benefits under a health plan who is furnished items or services (other than emergency services to which subsection
(a)applies or items and services to which subsection
(c)applies) in a plan year that, with respect to such plan or such coverage (as applicable), begins on or after January 1, 2022, at a participating facility by a nonparticipating provider, such provider shall not bill, and shall not hold liable, such individual for a payment amount for such an item or service furnished by such provider during a visit at such facility that is more than the cost-sharing amount for such item or service (as determined in accordance with section 2719A(e) of the Public Health Service Act, section 716(e) of the Employee Retirement Income Security Act of 1974, or section 9816(e) of the Internal Revenue Code of 1986, as applicable). Paragraph
(1)shall not apply with respect to items and services (other than items and services described in paragraph (3)) furnished to an individual enrolled in a group health plan or in health insurance coverage offered in the group or individual market by a health care provider that does not have a contractual relationship with such plan or coverage for furnishing such items and services if the following criteria are met: A written notice (as specified by the Secretary and in clear and understandable language) is provided by the provider to such individual, not later than 48 hours before such items and services are to be so furnished, that includes the following information: A statement verifying that the provider does not have such a relationship with such plan or coverage. The estimated amount that such provider may charge the individual for such items and services. A statement that the individual may seek such items or services from a health care provider that does have such a contractual relationship and a list, if feasible, of providers with such a relationship who are able to furnish such items and services involved. On the date such item or service is to be furnished, before such item or service is so furnished, the individual signs and dates such notice confirming receipt of the notice and consent of the individual to be so furnished such items and services. A copy of such signed and dated notice is provided by the provider to the plan or coverage. The items and services described in this paragraph are items and services furnished by a specified provider (as defined in subsection (f)(3)). In the case of an individual who is furnished items or services by a health care provider or health care facility for which a group health plan or health insurance issuer is required to make payment under section 2719A(i) of the Public Health Service Act, section 716(i) of the Employee Retirement Income Security Act of 1974, or section 9816(i) of the Internal Revenue Code of 1986, such provider or facility shall not bill, and shall not hold liable, such individual for a payment amount for such an item or service that is more than the cost-sharing amount for such item or service (as determined in accordance with section 2719A(i) of the Public Health Service Act, section 716(i) of the Employee Retirement Income Security Act of 1974, or section 9816(i) of the Internal Revenue Code of 1986, as applicable). A health care provider or health care facility shall comply with any requirement imposed on such provider or facility, respectively, under section 2719A(j) of the Public Health Service Act, 9816(j) of the Internal Revenue Code of 1986, or 716(j) of the Employee Retirement Income Security Act of 1974. Any health care provider or health care facility that violates a provision of this section shall be subject to a civil monetary penalty in an amount not to exceed $10,000 for each such violation. The provisions of section 1128A (other than subsection (a), subsection (b), the first sentence of subsection (c)(1), and subsection (o)) shall apply with respect to a civil monetary penalty imposed under this subsection in the same manner as such provisions apply with respect to a penalty or proceeding under subsection
(a)of such section. For purposes of this section and sections 1150D and 1150E: The terms during a visit , emergency department of a hospital , emergency medical condition , emergency services , independent freestanding emergency department , nonparticipating provider , nonparticipating facility , participating facility , participating provider have the meanings given such terms, respectively, in section 2719A(k) of the Public Health Service Act. The terms group health plan , group market , health insurance issuer , health insurance coverage , and individual market have the meanings given such terms, respectively, in section 2791 of the Public Health Service Act. The term specified provider , with respect to an individual with benefits under a group health plan or health insurance coverage and a hospital with a contractual relationship with such plan or coverage for furnishing items and services— means an ancillary health care provider, including emergency medicine providers or suppliers, anesthesiologists, pathologists, radiologists, neonatologists, assistant surgeons, hospitalists, intensivists, or other providers determined by the Secretary (including providers who furnish similar items and services as the providers specified in this paragraph); and includes, with respect to an item or service, any health care provider furnishing such item or service at such hospital if there is no health care provider at such hospital who can furnish such item or service who has such a relationship with such plan or coverage for furnishing such item or service. . Part A of title XI of the Social Security Act ( 42 U.S.C. 1301 et seq.), as amended by subsection (a), is further amended by adding at the end the following new sections: Beginning not later than 1 year after the date of the enactment of this section, each health care provider and health care facility shall establish a process under which such provider or facility transmits, to each health insurance issuer offering group or individual health insurance coverage and group health plan with which such provider or supplier has in effect a contractual relationship for furnishing items and services under such coverage or such plan, provider directory information (as defined in section 2719A(f)(6) of the Public Health Service Act, section 716(f)(6) of the Employee Retirement Income Security Act of 1974, or section 9816(f)(6) of the Internal Revenue Code of 1986, as applicable) with respect to such provider or facility, as applicable. Such provider or facility shall so transmit such information to such issuer offering such coverage or such group health plan— when there are any material changes (including a change in address, telephone number, or other contact information) to such provider directory information of the provider or facility with respect to such coverage offered by such issuer or with respect to such plan; and at any other time (including upon the request of such issuer or plan) determined appropriate by the provider, facility, or the Secretary. Each health care provider and health care facility shall, beginning January 1, 2022, in the case of an individual who schedules an item or service to be furnished to such individual by such provider or facility at least 3 business days before the date such item or service is to be so furnished, not later than 1 business day after the date of such scheduling (or, in the case of such an item or service scheduled at least 10 business days before the date such item or service is to be so furnished (or if requested by the individual), not later than 3 business days after the date of such scheduling or such request)— inquire if such individual is enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, or a Federal health care program (and if is so enrolled in such plan or coverage, seeking to have a claim for such item or service submitted to such plan or coverage); and provide a notification (in clear and understandable language) of the good faith estimate of the expected charges for furnishing such item or service (including any item or service that is reasonably expected to be provided in conjunction with such scheduled item or service) to— in the case the individual is enrolled in such a plan or such coverage (and is seeking to have a claim for such item or service submitted to such plan or coverage), such plan or issuer of such coverage; and in the case the individual is not described in subparagraph
(A)and not enrolled in a Federal health care program, the individual. A health care provider or health care facility shall, in the case of an individual furnished items and services by such provider or facility for which coverage is provided under a group health plan or group or individual health insurance coverage pursuant to section 2730 of such Act, section 9817 of the Internal Revenue Code of 1986, or section 717 of the Employee Retirement Income Security Act of 1974— accept payment from such plan or such issuer (as applicable) (and cost-sharing from such individual, if applicable, in accordance with subsection (a)(2)(C) of such section 2730, 9817, or 717) for such items and services as payment in full for such items and services; and continue to adhere to all policies, procedures, and quality standards imposed by such plan or issuer with respect to such individual and such items and services in the same manner as if such termination had not occurred. Beginning on January 1, 2022, a health care provider or health care facility may not initiate a process to seek reimbursement of payment for items and services furnished to an individual enrolled in a group health plan or health insurance coverage offered in the group or individual market more than 1 year after the date on which such items and services were so furnished. Except as provided in paragraph (2), any health care provider or health care facility that violates a provision of this section shall be subject to a civil monetary penalty in an amount not to exceed $10,000 for each such violation. The provisions of section 1128A (other than subsection (a), subsection (b), the first sentence of subsection (c)(1), and subsection (o)) shall apply with respect to a civil monetary penalty imposed under this paragraph in the same manner as such provisions apply with respect to a penalty or proceeding under subsection
(a)of such section. Each health care provider or health care facility that fails to transmit information as required under subsection
(a)shall be subject to a civil monetary penalty of $1,000 for each day such provider or facility (as applicable) fails to so transmit such information. The provisions of section 1128A (other than subsection (a), subsection (b), the first sentence of subsection (c)(1), subsection (d), and subsection (o)) shall apply with respect to a civil monetary penalty imposed under this paragraph in the same manner as such provisions apply with respect to a penalty or proceeding under subsection
(a)of such section. Not later than July 1, 2021, the Secretary shall establish a process (in this subsection referred to as the patient-provider dispute resolution process ) under which an uninsured individual, with respect to an item or service, who received, pursuant to section 1150D(b), from a health care provider or health care facility a good-faith estimate of the expected charges for furnishing such item or service to such individual and who after being furnished such item or service by such provider or facility is billed by such provider or facility for such item or service for charges that are substantially in excess of such estimate, may seek a determination from a selected dispute resolution entity for the charges to be paid by such individual (in lieu of such amount so billed) to such provider or facility for such item or service. For purposes of this subsection, the term uninsured individual means, with respect to an item or service, an individual who does not have benefits for such item or service under a group health plan, health insurance coverage offered in the group or individual market by a health insurance issuer, Federal health care program (as defined in section 1128B(f)), or a health benefits plan under chapter 89 of title 5, United States Code (or an individual who has benefits for such item or service under a group health plan or health insurance coverage offered in the group or individual market by a health insurance issuer, but who does not seek to have a claim for such item or service submitted to such plan or coverage). Under the patient-provider dispute resolution process, the Secretary shall, with respect to a determination sought by an individual under subsection (a), with respect to charges to be paid by such individual to a health care provider or health care facility described in such paragraph for an item or service furnished to such individual by such provider or facility, provide for— a method to select to make such determination an entity certified under subsection
(d)that— is not a party to such determination or an employee or agent of such party; does not have a material familial, financial, or professional relationship with such a party; and does not otherwise have a conflict of interest with such a party (as determined by the Secretary); and the provision of a notification of such selection to the individual and the provider or facility (as applicable) party to such determination. An entity selected pursuant to the previous sentence to make a determination described in such sentence shall be referred to in this subsection as the selected dispute resolution entity with respect to such determination. The Secretary shall establish a fee to participate in the patient-provider dispute resolution process in such a manner as to not create a barrier to an uninsured individual’s access to such process. The Secretary shall establish or recognize a process to certify entities under this subparagraph. Such process shall ensure that an entity so certified satisfies at least the criteria specified in section 2719A(j)(7) of the Public Health Service Act. .
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Sec. 8
Prohibiting balance billing practices by providers for emergency services, for services furnished by nonparticipating provider at participating facility, and in certain cases of misinformation
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